Concerns Regarding Parents and Families

In addition to spawning massive disruptions in daily home, school, and work lives, critical illness in children can have significant and far-reaching emotional effects on parents and families (Holmes 2004; Rothstein 1980). Miles and Carter (1982) were among the first to describe specific parental stressors inherent in the PICU, including unfamiliar and daunting sights, sounds, and procedures that are common in the environment; the altered and sometimes distressing appearance and behavior of the child; challenges and alterations in the parental role; the prolonged separation from home; and issues with staff communication and behavior. Mothers whose children required PICU level of care experienced greater state anxiety, depression, confusion, and anger than did mothers of healthy nonhospital-ized children and mothers whose children needed hospitalization on general pediatric units (Beren-baum and Hatcher 1992; Board and Ryan-Wenger 2003). Likewise, fathers of PICU patients reported higher levels of perceived stress and stress symptomatology than did fathers of pediatric patients on general hospital units (Board 2004). Researchers investigating the short-term psychological impact of critical care hospitalization on family members have documented heightened anxiety, depressive symptoms, and acute and posttraumatic stress symptoms that warrant early case identification and intervention (Bronner et al. 2008a; Paparrigopoulos et al. 2006; Shears et al. 2005).

Parents of a child in the NICU are faced with unique stressors related to the child's prematurity and the parents' unexpectedly early entry into parenthood of a medically fragile infant. Other common parental NICU experiences include postpartum depression, inability to hold or care for one's newborn child who has been "farmed out" of one's care for an indefinite period (Aisenstein 1987), stressors related to multiple births, residual matters involving assis-tive reproduction technology (e.g., in vitro fertilization), themes of loss from missing the typical rejoic ing that is characteristic of welcoming a newborn into the world, and continual worry about the child's survival. The mental health consultant may be invaluable in offering support related to such themes, particularly when families are separated from their traditional support networks (Nottage 2005).

A growing body of literature has documented ASD and PTSD symptomatology in parents of critically ill children. Balluffi et al. (2004) found that 32% of parents of children in a PICU met diagnostic criteria for ASD, and 21% met criteria for PTSD upon follow-up. Recent results from a study in the Netherlands (Bronner et al. 2008a) indicated that more than three-quarters of parents of PICU-hospi-talized children evidenced persistent subthreshold PTSD symptomatology. ASD and PTSD symptoms have been extensively documented in parents of infants requiring NICU hospitalization (e.g., Hol-ditch-Davis et al. 2003; Lefkowitz et al. 2008; Shaw et al. 2006), and evidence indicates that parents' traumatic experiences related to their infants' NICU hospitalization may have both short-term and persistent effects on later behaviors, such as infant sleeping and eating (Pierrehumbert et al. 2003), and attachment and family functioning (Mayes 2003). Diagnostic rates of ASD and PTSD are higher among parents of children requiring critical care than among parents of children on general medical wards (Rees et al. 2004), and various risk factors for the development of traumatic stress symptoms in parents have been identified, including parents' perceptions of life threat to their children, the unexpected nature of the hospitalization, witnessing their children undergoing invasive or painful procedures or demonstrating emotional distress, and traumatic stress symptoms in the children (Ward-Beg-noche 2007). Parental acute stress while in the PICU is predictive of subsequent PTSD symptoms (Balluffi et al. 2004).

Brothers and sisters of children requiring critical care hospitalization have unique needs and can benefit from psychosocial assessment and emotional support. Often, parents seek help about ways to "talk to" and support their other children at home, particularly advice about visiting the PICU and balancing the demands of child care and family life when one child requires hospitalization (DeMaso et al. 1997). At Children's Hospital Boston, we have found that about 10% of referrals for psychological services were generated on behalf of siblings. Brothers and sisters can experience an array of emotional responses to a sibling's hospitalization and the con comitant disruption in caregiving arrangements and family life, including increased stress, fearfulness, worries, sadness, or anger (Sourkes 1995; Spinnetta 1981). Because siblings can be particularly susceptible to complicated feelings of isolation, displacement, jealousy, and guilt when their sibling has a critical illness and necessarily demands so much of the parents' and family's resources to cope effectively, they can benefit greatly from psychosocial support.

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